ACOG committee opinion no. 422: At-risk drinking and illicit drug use: Ethical issues in obstetric and gynecologic practice.(2008). Obstetrics and Gynecology, 112(6), 1449-1460.

Drug and alcohol abuse is a major health problem for American women regardless of their socioeconomic status, race, ethnicity, and age. It is costly to individuals and to society. Obstetrician-gynecologists have an ethical obligation to learn and use a protocol for universal screening questions, brief intervention, and referral to treatment in order to provide patients and their families with medical care that is state-of-the-art, comprehensive, and effective. In this ommittee Opinion, the American College of Obstetricians and Gynecologists’ Committee on Ethics proposes an ethical rationale for this protocol in both obstetric and gynecologic practice, offers a practical aid for incorporating such care, and provides guidelines for resolving common ethical dilemmas related to drug and alcohol use that arise in the clinical setting. © 2008 by The American College of Obstetricians and Gynecologists.

Bailey, B. A., & Sokol, R. J. (2008). Pregnancy and alcohol use: Evidence and recommendations for prenatal care. Clinical Obstetrics and Gynecology, 51(2), 436-444.

Pregnancy alcohol consumption has been linked to poor birth outcomes and long-term developmental problems. Despite this, a significant number of women drink during pregnancy. Although most prenatal care providers are asking women about alcohol use, validated screening tools are infrequently employed. Research has demonstrated that currently available screening methods and intervention techniques are effective in identifying and reducing pregnancy drinking. Implementing universal screening and appropriate intervention for pregnancy alcohol use should be a priority for prenatal care providers, as these efforts could substantially improve pregnancy, birth, and longer term developmental outcomes for those affected. © 2008 Lippincott Williams & Wilkins, Inc.

Balachova, T. N., Bonner, B. L., Isurina, G. L., & Tsvetkova, L. A. (2007). Use of focus groups in developing FAS/FASD prevention in russia. Substance use & Misuse, 42(5), 881-894. doi:10.1080/10826080701202601

Fetal alcohol syndrome is a severe outcome of alcohol use during pregnancy, and the rates may be higher in countries with greater use of alcohol. To obtain information from Russian physicians (N = 23), women (N = 23), and male partners (N = 5), focus groups were conducted with 51 participants in St. Petersburg, Russia. The main objective was to determine the participants’ knowledge, attitudes, and behavior related to drinking during pregnancy. Data were analyzed using ATLAS-ti 5.0. The results will be used to develop a survey of Russian professionals and women leading to FAS prevention programming. The study’s limitations are described. (PsycINFO Database Record (c) 2009 APA, all rights reserved) (journal abstract)

Baydala, L., Sherman, J., Rasmussen, C., Wikman, E., & Janzen, H. (2006). ADHD characteristics in canadian aboriginal children. Journal of Attention Disorders, 9(4), 642-647.

Objective: The authors examine how many Aboriginal children attending two reservation-based elementary schools in Northern Alberta, Canada, would demonstrate symptoms associated with ADHD using standardized parent and teacher questionnaires. Method: Seventy-five Aboriginal children in Grades 1 through 4 are tested. Seventeen of the 75 (22.7%) Aboriginal children demonstrated a match on parent and teacher forms, with T-scores greater than 1.5 standard deviations from the mean on the Conners’ ADHD Index, Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) Hyperactive/Impulsive Index, DSM-IV Inattentive Index, and/or DSM-IV Total Combined T-score. Results: The number of Aboriginal children found to have symptoms associated with ADHD is significantly higher than expected based on prevalence rates in the general population. Conclusion: These findings suggest either a high prevalence of ADHD in Aboriginal children or unique learning and behavioral patterns in Aboriginal children that may erroneously lead to a diagnosis of ADHD if screening questionnaires are used. © 2006 Sage Publications.

Benz, J., Rasmussen, C., & Andrew, G. (2009). Diagnosing fetal alcohol spectrum disorder: History challenges and future directions. Paediatrics and Child Health, 14(4), 231-237.

Eetal alcohol spectrum disorder (FASD) is one of the most common preventable causes of developmenta disability, and is currently one of the most pressing public health concerns in Canada. FASD refers to the range of physical, mental, behavioural and learning disabilities that an individual may acquire as a result of maternal alcobol consumption. In the present paper, the history of the diagnostic approach to alcohol-related disorders over the past 35 years is reviewed. Research supporting the importance of early diagnosis for the long-term outcomes and management of individuals with FASD is presented, and challenges that have plagued efforts to efficiently diagnose individuals with FASD are discussed. Finally, the study reviews the future directions and implications regarding current diagnostic strategies. © 2009 Pulsus Group Inc. All rights reserved.

Bertrand, J. (2009). Interventions for children with fetal alcohol spectrum disorders (FASDs): Overview of findings for five innovative research projects. Research in Developmental Disabilities, 30(5), 986-1006.

It is well established that prenatal exposure to alcohol causes damage to the developing fetus, resulting in a spectrum of disorders known as fetal alcohol spectrum disorders (FASDs). Although our understanding of the deficits and disturbances associated with FASDs is far from complete, there are consistent findings indicating these are serious, lifelong disabilities-especially when these disabilities result from central nervous system damage. Until recently, information and strategies for interventions specific to individuals with FASDs have been gleaned from interventions used with people with other disabilities and from the practical wisdom gained by parents and clinicians through trial and error or shared through informal networks. Although informative to a limited degree, such interventions have been implemented without being evaluated systematically or scientifically. The purpose of this article is to provide a brief overview of a general intervention framework developed for individuals with FASDs and the methods and general findings of five specific intervention research studies conducted within this framework. The studies evaluated five different interventions in five diverse locations in the United States, with different segments of the FASD population. Nonetheless, all participants showed improvement in the target behaviors or skills, with four studies achieving statistical significance in treatment outcomes. Important lessons emerged from these five interventions that may explain success: including parent education or training, teaching children specific skills they would usually learn by observation or abstraction, and integration into existing systems of treatment. A major implication of these research studies for families dealing with FASDs is that there are now interventions available that can address their children’s needs and that can be presented as scientifically validated and efficacious to intervention agents such as schools, social services, and mental health providers. In the field of FASD research and clinical service, a common theme reported by families has been that clinicians and professionals have been reluctant to diagnose their children because there were no known effective treatments. Results of these five studies dispel that concern by demonstrating several interventions that have been shown to improve the lives of individuals with FASDs and their families.

Bertrand, J., Floyd, L. L., & Weber, M. K. (2005). Guidelines for identifying and referring persons with fetal alcohol syndrome. Recommendations and Reports : Morbidity and Mortality Weekly Report. Centers for Disease Control, 54(RR-11), 1-14.

Fetal alcohol syndrome (FAS) results from maternal alcohol use during pregnancy and carries lifelong consequences. Early recognition of FAS can result in better outcomes for persons who receive a diagnosis. Although FAS was first identified in 1973, persons with this condition often do not receive a diagnosis. In 2002, Congress directed CDC to update and refine diagnostic and referral criteria for FAS, incorporating recent scientific and clinical evidence. In 2002, CDC convened a scientific working group (SWG) of persons with expertise in FAS research, diagnosis, and treatment to draft criteria for diagnosing FAS. This report summarizes the diagnostic guidelines drafted by the SWG, provides recommendations for when and how to refer a person suspected of having problems related to prenatal alcohol exposure, and assesses existing practices for creating supportive environments that might prevent long-term adverse consequences associated with FAS. The guidelines were created on the basis of a review of scientific evidence, clinical expertise, and the experiences of families affected by FAS regarding the physical and neuropsychologic features of FAS and the medical, educational, and social services needed by persons with FAS and their families. The guidelines are intended to facilitate early identification of persons affected by prenatal exposure to alcohol so they and their families can receive services that enable them to achieve healthy lives and reach their full potential. This report also includes recommendations to enhance identification of and intervention for women at risk for alcohol-exposed pregnancies. Additional data are needed to develop diagnostic criteria for other related disorders (e.g., alcohol-related neurodevelopmental disorder).

Boulter, L. (2007). The effectiveness of peer-led FAS/FAE prevention presentations in middle and high schools. Journal of Alcohol and Drug Education, 51(3), 7-26.

Pregnant women and women who might become pregnant, including middle school- and high school-age adolescents, continue to consume alcohol, placing themselves at risk of having a child with the effects of prenatal alcohol exposure. However, most prevention programs that attempt to increase public awareness and knowledge of FAS and related disorders have had limited success and are inappropriate for 11 through 17-year-old youth. This study assessed the effectiveness of a pilot multimedia presentation that was implemented by peers and slightly older college students and incorporated into the middle school and high school health education programs. Posttests and follow-up assessments were compared to pretest scores to measure change in knowledge related to the effects of prenatal alcohol exposure and understanding of the overall purpose of the program. In general, students’ overall knowledge of presentation content increased from pretest to posttest. Overall follow-up scores showed that students’ retention of the presentation information had increased since the posttest. The findings suggest that FAS/FAE presentations led by peers and utilizing a multimedia/discussion format effectively increase middle school and high school students’ knowledge of the effects of alcohol consumption during pregnancy.

Brown, J. D., Bednar, L. M., & Sigvaldason, N. (2007). Causes of placement breakdown for foster children affected by alcohol. Child & Adolescent Social Work Journal, 24(4), 313-332. doi:10.1007/s10560-007-0086-9

A sample of 63 licensed foster parents who had fostered a child who was diagnosed with a disorder in the fetal alcohol spectrum were asked “What would make you consider ending a placement with a child who has a fetal alcohol spectrum disorder?” The responses to this question were grouped together by foster parents. The grouping data were subjected to multidimensional scaling and cluster analysis. Results indicated that foster parents would consider ending a placement if they felt they were being taken for granted, burned out, had insufficient information about the child, or if the child had serious behavior problems, caused harm to others in the home, or did not comply with household rules and routines. Discrepancies between the literature and study results were described and suggestions for future research were made. (PsycINFO Database Record (c) 2009 APA, all rights reserved) (journal abstract)

Brown, J. D., Sigvaldason, N., & Bednar, L. M. (2005). Foster parent perceptions of placement needs for children with a fetal alcohol spectrum disorder. Children and Youth Services Review, 27(3), 309-327.

A random sample of 63 foster parents from a central Canadian province was asked “What do you need for a successful placement for a child who has a fetal alcohol spectrum disorder?”. The responses to this question were edited for clarity and sorted into piles of like statements by foster parents. Two types of statistical analysis were applied to the sorting of the statements to describe the relationship between statements and their groupings. The major concepts were identified according to the contents of the cluster, and a map was constructed to provide a graphic representation of the conceptualization process. Foster parents described the need for social support, material support, a structured home environment, professionals, other foster parents, understanding of fetal alcohol spectrum disorders, the right kind of personality, and organization skills. Discrepancies between the existing literature and study results were described, and suggestions for future research were made. © 2004 Elsevier Ltd. All rights reserved.

Burd, L., Carlson, C., & Kerbeshian, J. (2007). Fetal alcohol spectrum disorders and mental illness. International Journal on Disability and Human Development, 6(4), 383-396.

Objective: To discuss relevant issues in the diagnosis of mental disorders comorbid with fetal alcohol spectrum disorders (FASD). Methods: We present a theoretical model of the effect of prenatal alcohol exposure on neurobehavioral development and a systematic review of published data on the mental disorders in subjects with an FASD. Results: Prenatal alcohol exposure is associated with high rates of mental disorders. We found 48 papers reporting on 3,343 subjects. The most common mental disorder comorbid with FASD is attention deficit – hyperactivity disorder occurring in 48% of subjects with FASD. Cognitive impairment is also very common. Discussion: Prenatal alcohol exposure appears to have differential effects on outcomes leading to large increases in rates of some but apparently not most mental disorders. We discuss strategies to improve the diagnosis of mental disorders in FASD and the multiplicity of uses for this important data. Copyright © Freund Publishing House Limited.

Burd, L., & Christensen, T. (2009). Treatment of fetal alcohol spectrum disorders: Are we ready yet? Journal of Clinical Psychopharmacology, 29(1), 1-4. doi:10.1097/JCP.0b013e318192eaeb

Prenatal alcohol use is a major public health problem around the world. Among women who drink,13% have more than 7 drinks per week. Prenatal alcohol exposure has multiple adverse outcomes—the most serious are mortality and fetal alcohol spectrum disorders (FASD). Fetal alcohol spectrum disorders increase susceptibility for a wide range of mental disorders and social impairments that vary over the life span. The impairments from these neuropsychiatric impairments are the defining features of outcome for most children, adolescents, and adults. The diagnosis of FASD is difficult, and considerable attention needs to be given to improve neuropsychiatric assessments and to appropriately expand the diagnostic criteria to capture children who have adverse neurocognitive and psychosocial impairments from prenatal alcohol exposure. Careful planning to monitor adverse effects will be crucial because children with FASD have multiple prenatal exposures (maternal smoking, poor diet, and other substance abuse). The prevalence of congenital heart defects is increased in children with FASD. (PsycINFO Database Record (c) 2009 APA, all rights reserved)

Burd, L. J. (2007). Interventions in FASD: We must do better. Child: Care, Health and Development, 33(4), 398-400.

Caley, L. M., Shipkey, N., Winkelman, T., Dunlap, C., & Rivera, S. (2006). Evidence-based review of nursing interventions to prevent secondary disabilities in fetal alcohol spectrum disorder. Pediatric Nursing, 32(2), 155-162.

Chandrasena, A. N., Mukherjee, R. A. S., & Turk, J. (2009). Fetal alcohol spectrum disorders: An overview of interventions for affected individuals. Child and Adolescent Mental Health, 14(4), 162-167.

Whilst much has been written about understanding the diagnostic and underlying pathological processes related to prenatal alcohol exposure, far less has been directed at the management of affected individuals. We undertake a review of the literature focusing on a range of interventions including psychological, social, educational, pharmacological as well recent advances and directions. This paper is designed to give an overview on the management of this complex disorder. © 2008 Association for Child and Adolescent Mental Health.

Christopher, S., Dunnagan, T., Haynes, G., & Stiff, L. (2007). Determining client need in a multi-state fetal alcohol syndrome consortium: From training to practice. Behavioral and Brain Functions, 3 doi:10.1186/1744-9081-3-10

Background: A multi-state consortium was developed in the US to conduct baseline data collection and intervention research on fetal alcohol syndrome. Each state employed support specialists whose job it was to reduce or eliminate alcohol consumption in women who were at high risk for drinking alcohol during their pregnancy. The purpose of this paper is to report how support specialists in three primarily rural/frontier states were trained to assess client need and how client need was actually assessed in the field. Methods: A qualitative process evaluation was conducted using semi-structured interviews. Interviews were conducted with state staff involved in support specialist training and consortium activities and the support specialists themselves. Inductive analyses were conducted with interview data. Results: Need determination varied by state and for one state within the state. How support specialists were trained to assess need and how need was assessed in the field was mostly congruent. Conclusion: Process evaluation is an effective method for providing practical and useful answers to questions that cannot be answered by outcome evaluation alone. (PsycINFO Database Record (c) 2009 APA, all rights reserved) (journal abstract)

Chudley, A. E., Conry, J., Cook, J. L., Loock, C., Rosales, T., & LeBlanc, N. (2005). Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. Canadian Medical Association Journal, 172(5 SUPPL.)

THE DIAGNOSIS OF FETAL ALCOHOL SPECTRUM DISORDER (FASD) is complex and guidelines are warranted. A subcommittee of the Public Health Agency of Canada’s National Advisory Committee on Fetal Alcohol Spectrum Disorder reviewed, analysed and integrated current approaches to diagnosis to reach agreement on a standard in Canada. The purpose of this paper is to review and clarify the use of current diagnostic systems and make recommendations on their application for diagnosis of FASD-related disabilities in people of all ages. The guidelines are based on widespread consultation of expert practitioners and partners in the field. The guidelines have been organized into 7 categories: screening and referral; the physical examination and differential diagnosis; the neurobehavioural assessment; and treatment and follow-up; maternal alcohol history in pregnancy; diagnostic criteria for fetal alcohol syndrome (FAS), partial FAS and alcohol-related neurodevelopmental disorder; and harmonization of Institute of Medicine and 4-Digit Diagnostic Code approaches. The diagnosis requires a comprehensive history and physical and neurobehavioural assessments; a multidisciplinary approach is necessary. These are the first Canadian guidelines for the diagnosis of FAS and its related disabilities, developed by broad-based consultation among experts in diagnosis. © 2005 CMA Media Inc.

Chudley, A. E., Kilgour, A. R., Cranston, M., & Edwards, M. (2007). Challenges of diagnosis in fetal alcohol syndrome and fetal alcohol spectrum disorder in the adult. American Journal of Medical Genetics, Part C: Seminars in Medical Genetics, 145(3), 261-272.

Adults with fetal alcohol syndrome (FAS) and the subsets of individuals with attenuated phenotype subsumed under the umbrella term of fetal alcohol spectrum disorder (FASD) provide clinicians with a challenge. Compounding this, FASD is different from most genetic syndromes since a specific diagnostic biological test is not available. The diagnosis first needs to be suspected and confirmation requires a diagnostic assessment that is best carried out in the context of a multi-disciplinary team approach. There is surprisingly little research published on the prevalence, natural history, medical, and social complications relevant to adults with FASD. The evidence that is emerging suggests that this disorder is common, and that services to diagnose and treat these individuals are limited. Adults with FASD have a higher incidence of impairments in social adaptive and executive function, and a higher degree of psychopathology when compared to the general population. The impact of FASD has significant and serious effects on those affected with FASD, their families, and our communities. There is a need for improved access to diagnosis, and more research and evaluation of interventions currently in use. In this paper, we describe the current diagnostic criteria, the differential diagnosis, the prevalence, natural history, the behavioral and mental health consequences, medical and social management issues, and interventions for adults affected with this disorder. © 2007 Wiley-Liss, Inc.

Clarren, S. K., & Lutke, J. (2008). Building clinical capacity for fetal alcohol spectrum disorder diagnoses in Western and Northern Canada. Canadian Journal of Clinical Pharmacology, 15(2)

Background: Fetal alcohol syndrome and fetal alcohol spectrum disorder are common problems. In response to this problem the Canada Northwest FASD Research Network was established in 2005 by the Canada Northwest FASD Ministerial Partnership. This study was conducted to determine the FASD clinical activity in Canada Northwest. Methods: The Network identified all clinical programs via Internet sites, provincial postings and professional word of mouth references that purported to do FASD assessments regularly using a multidisciplinary assessment team. Each of these programs was sent a questionnaire asking about clinical capacity, aggregate diagnostic results, team composition, time of clinical assessment, and cost of assessment. Results: Of the 27 programs identified to receive the questionnaire 15 programs responded. These programs were determined to have evaluated about 85% of the patients evaluated by all the programs. The total 7 jurisdictional capacity for FASD diagnosis was 816 evaluations in 2005 and projected to be 975 in 2006. Selection methods for appointing patients for assessment seemed excellent as 23% of those assessed were found to have FAS or pFAS and another 44% had other forms of FASD. The most common professionals to participate in the team evaluations were Paediatricians, Clinical Psychologists, Speech and Language Pathologists and Occupational Therapists. Interpretation: Clinics are developing in western and northern Canada to diagnose patients with FASD. Comparing the experiences of these clinics can help to determine the continued need to increase diagnostic capacity, standardize diagnostic approaches to assure consistency of approach and diagnosis across the sites and appropriately staff and fund the programs. ©2008 Canadian Society for Clinical Pharmacology. All rights reserved.

Coles, C. D., Strickland, D. C., Padgett, L., & Bellmoff, L. (2007). Games that ”work”: Using computer games to teach alcohol-affected children about fire and street safety. Research in Developmental Disabilities: A Multidisciplinary Journal, 28(5), 518-530.

Unintentional injuries are a leading cause of death and disability for children. Those with developmental disabilities, including children affected by prenatal alcohol exposure, are at highest risk for injuries. Although teaching safety skills is recommended to prevent injury, cognitive limitations and behavioral problems characteristic of children with fetal alcohol spectrum disorder make teaching these skills challenging for parents and teachers. In the current study, 32 children, ages 4-10, diagnosed with fetal alcohol syndrome (FAS) and partial FAS, learned fire and street safety through computer games that employed “virtual worlds” to teach recommended safety skills. Children were pretested on verbal knowledge of four safety elements for both fire and street safety conditions and then randomly assigned to one condition. After playing the game until mastery, children were retested verbally and asked to “generalize” their newly acquired skills in a behavioral context. They were retested after 1 week follow-up. Children showed significantly better knowledge of the game to which they were exposed, immediately and at follow-up, and the majority (72%) was able to generalize all four steps within a behavioral setting. Results suggested that this is a highly effective method for teaching safety skills to high-risk children who have learning difficulties.

Cronk, C., & Weiss, M. (2007). Diagnosis, surveillance and screening for fetal alcohol syndrome spectrum disorders: Methods and dilemmas. International Journal on Disability and Human Development, 6(4), 343-359.

Fetal Alcohol Spectrum Disorder (FASD) is a prevalent preventable disorder with a significant societal burden related to the cognitive and behavioral disabilities associated with this disorder. This paper reviews the published work on FASD diagnosis, surveillance, and screening programs. Challenges inherent to FASD diagnosis remain and complicate attempts to estimate FAS prevalence. In addition, the drive toward diagnostic accuracy has led to screening children at school ages after many disabilities associated with FASD are established. We present the design and selected findings from a regional multi-stage screening project piloted in Wisconsin. Small for gestational age (SGA) newborns with birth head circumference less than 10th percentile were selected in the first screening stages. Those meeting these criteria were evaluated for growth, development and FAS facial features at about 2 years of age. Of newborns meeting the initial screening criteria, 30% demonstrated growth deficits and developmental delays at about 2 years of age. Children with any FAS facial feature (of 177 children assessed, n = 13 with 2 or 3 facial findings, n = 77 with one facial finding) showed greater deficits in growth and a greater proportion were developmentally delayed. The findings demonstrate the potential value of embedding screening for FAS within a multistage screening method to identify infants at risk for any developmental delay. Because this model would be a part of larger population screening for developmental delay, cost efficiencies could be achieved. Problems relating to protection and confidentiality that inevitably accompany screening to identify FASD would also be reduced. (PsycINFO Database Record (c) 2009 APA, all rights reserved) (journal abstract)